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Recognize the patient and the family as the unit of care:
- Assess and document who comprises the family; it may not be a traditional
one.
Assess the patient’s and family’s decision-making style
and preferences:
- Clarify and document level of participation patient and/or family desire
in choosing treatment options.
Address conflicts in decision making within the family and between staff and
family:
- Explicitly address conflicts that arise within families and
help families resolve these conflicts.
- Explicitly address conflicts that arise
between staff and family members.
- Train staff in conflict resolution techniques.
Assess together with appropriate clinical consultants, the patient’s
capacity to participate in decision-making about treatment and document assessment.
Initiate advance care planning with the patient and family:
- Take
the lead in involving patient and/or family in treatment decisions by convening
a family conference with members of the health care team and available
family members. If patient is able to participate, hold conference at the bedside.
Clarify and document the status of the patient’s advance directive:
- If
the patient has completed an advance directive, review with the patient and/or
family upon admission to the ICU and document discussion
- Place the advance
directive in the chart and “flag” the chart.
Identify the health care proxy and surrogate decision-maker:
- For
patients who lack decision-making ability, assess and document the family’s
knowledge of the patient’s verbal wishes and goals about treatment.
Clarify and document resuscitation orders:
- Distinguish do-not-resuscitate
(DNR) orders from withholding and withdrawing life-sustaining treatment;
policies and guidelines for these should be distinct.
- Document discussions
with patient and/or family about cardiopulmonary
resuscitation (CPR).
- Utilize preprinted “family discussion sheet” where
informal
and formal discussions with family members may be documented.
Assure patients and families that decision making by the health care team
will incorporate their preferences.
Follow ethical and legal guidelines for patients who lack both capacity
and a surrogate decision-maker:
- Establish a written policy detailing
these guidelines.
Establish and document clear, realistic and appropriate goals of
care in consultation with the patient and family:
- Ensure that treatments
reflect the goals of care.
- Identify a time frame for the reassessment of
treatment goals and set up follow-up meetings with the patient and/or family
to discuss progress towards
goals.
Help the patient and family assess the benefits and burdens of alternative
treatment choices as the patient condition changes.
Forgo life-sustaining treatments in a way that ensures patient and
family preferences are elicited and respected:
- Develop pathways to
improve the quality of care in the setting of withdrawing life-sustaining
treatments.
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Promoting Excellence in End-of-Life Care is a national program of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources.
